Special Article
Medical Aspects of the Persistent Vegetative State
N Engl J Med 1994; 330:1572-1579June 2, 1994
This article has multiple parts: First of Two Parts
- Article
Prognosis for Recovery
There are two dimensions of recovery from a persistent vegetative state: recovery of consciousness and recovery of function. Recovery of consciousness can be verified by reliable evidence of awareness of self and the environment, consistent voluntary behavioral responses to visual and auditory stimuli, and interaction with others. Recovery of function is characterized by communication, the ability to learn and to perform adaptive tasks, mobility, self-care, and participation in recreational or vocational activities. Recovery of consciousness may occur without functional recovery, but functional recovery cannot occur without recovery of consciousness. In some instances, during the early stages of recovery of consciousness, external manifestations may not be immediately apparent. Repeated examinations over time are necessary to ensure the consistency and accuracy of signs of recovery.
The prognosis for cognitive and functional recovery depends on the cause of the underlying brain disease. The Glasgow Outcome Scale classifies outcome in five categories: good recovery, moderate disability, severe disability, persistent vegetative state, and death108. Patients with a good recovery have the capacity to resume normal occupational and social activities, although there may be minor physical or mental deficits or symptoms. Patients with moderate disability are independent and can resume almost all activities of daily living. They are disabled to the extent that they can no longer participate in a variety of social and work activities. Patients with severe disability are no longer capable of engaging in most previous personal, social, and work activities. Such patients have limited communication skills and abnormal behavioral and emotional responses. They are partially or totally dependent on assistance from others in performing the activities of daily living.
Acute Traumatic and Nontraumatic Injuries
Recovery of consciousness after 12 months is unlikely in adults and children who have had traumatic injuries. Recovery of consciousness after three months is rare in adults and children with nontraumatic injuries (Figure 1Figure 1
Outcome for Patients in a Persistent Vegetative State (PVS) after a Traumatic or Nontraumatic Injury. and Table 3Table 3
Incidence of Recovery of Consciousness and Function in Adults and Children in a Persistent Vegetative State (PVS) after Traumatic or Nontraumatic Brain Injury. and Table 4Table 4
Probability of Recovery of Consciousness and Function at 12 Months in Adults and Children in a Persistent Vegetative State (PVS) Three or Six Months after Traumatic or Nontraumatic Injury.).Traumatic Injuries in Adults
For patients in a vegetative state as a result of traumatic brain injury, the prognosis for recovery remains unfavorable. Recovery of consciousness and function was determined by reviewing data from previously described series of patients rather than individual case reports. Data were available on 434 patients in a vegetative state one month after a severe head injury (Figure 1 and Table 3)47,49,50,106, 109,110 (and Tillet JA: personal communication). Recovery of consciousness varied with time. Three months after injury, 33 percent of the patients had recovered consciousness; 67 percent had died or remained in a vegetative state. Recovery had occurred in 46 percent of the patients at 6 months and in 52 percent at 12 months. Recovery after 12 months was reported in only 7 of the 434 patients47,49. One patient recovered consciousness 30 months after injury and remained severely disabled47, 111. The Traumatic Coma Data Bank study reported that 6 of 93 adult patients in a vegetative state recovered consciousness one to three years after injury49. Four of these six patients had severe disability, and one had moderate disability; the status of the sixth patient could not be determined. Five of the six patients were under 30 years of age. There have been no other well-documented reports of recovery of consciousness in patients in a persistent vegetative state more than 12 months after a traumatic injury.
Good recovery of function is also unlikely. Among the 434 patients in a vegetative state, the outcome at one year, according to the Glasgow Outcome Scale, was as follows: 33 percent had died, 15 percent were in a persistent vegetative state, 28 percent had severe disability, 17 percent had moderate disability, and 7 percent had a good recovery. Of the 7 percent of patients who had a good recovery, over half showed signs of improvement within three months after injury, and almost all within six months after injury. For the entire group of 434 patients, the incidence of a good recovery beginning 6 to 12 months after injury was less than 0.5 percent. No patient had a good recovery that began after 12 months. Among patients who recovered with moderate or severe disability, almost all showed signs of improvement within six months after injury. A later recovery was almost invariably associated with severe disability.
Age is an important factor affecting outcome. Among patients who have had traumatic injuries, those over the age of 40 years have a smaller chance of improvement than those who are younger; recovery without severe disability is rare, especially after three months47. Ventilatory dysfunction, lack of early motor reactivity, late-onset epilepsy, or the development of hydrocephalus may also indicate a poorer prognosis for recovery of awareness55, 112.
Nontraumatic Injuries in Adults
Adults in a coma immediately after a nontraumatic injury have a poorer prognosis than those in a coma after a traumatic injury, with 85 percent or more dying within the first month after the insult or remaining in a vegetative state52,56. Later recovery of consciousness and function was determined by reviewing data from previously described series consisting of 169 patients who were in a vegetative state one month after a nontraumatic injury (Figure 1 and Table 3)37,42,43,51. Recovery of consciousness after a nontraumatic injury is unlikely. Of the 169 patients with such injuries, only 11 percent had recovered consciousness three months after injury; 89 percent remained in a vegetative state or had died (Figure 1 and Table 3). Six months after injury, only two additional patients had recovered consciousness. One year after injury, 15 percent of the 169 patients had recovered consciousness, 32 percent were in a persistent vegetative state, and 53 percent had died.
Recovery of function in the 15 percent of patients who regained consciousness was extremely poor. Only one patient had a good recovery. Two additional reports of individual patients with good functional recovery after nontraumatic injury have been published. In both patients, improvement began within two months after a hypoxic injury78, 113. There have been reports of five other patients who began to recover from a vegetative state more than six months after a nontraumatic injury. Two had moderate disability, and three had severe disability (Table 5Table 5
Verified Reports of Five Patients with a Late Recovery from a Persistent Vegetative State (PVS).).Traumatic Injuries in Children
Recovery of consciousness and function in children after a traumatic injury was determined by reviewing data on 106 patients in previously reported series (Figure 1 and Table 3)49, 110,117-119 (and Tillet JA: personal communication). The prognosis for recovery of consciousness after a traumatic injury is slightly better in children than in adults (Figure 1). Of the 106 children in a vegetative state one month after a severe head injury, 24 percent had regained consciousness within three months. At one year, only 29 percent remained in a vegetative state, 9 percent had died, and 62 percent had recovered consciousness. None of the children recovered consciousness after 12 months.
Recovery of function was comparable to that in the adults. At one year, 35 percent of the children had severe disability, 16 percent had moderate disability, and 11 percent had made a good recovery. As in adults, if recovery of consciousness from the post-traumatic vegetative state began before six months, a higher functional grade of recovery was likely118. However, some children had a good recovery at six months or had only moderate disability at one year, whereas in adults recovery after six months was usually associated with severe disability.
Nontraumatic Injuries in Children
The prognosis for recovery after nontraumatic injuries in children appears to be similar to the prognosis for adults. However, the available data are limited, since previously described series total only 45 patients (Figure 1 and Table 3)44,66.86. Recovery of consciousness in children, as in adults, was primarily observed within the first three months after injury. By that time, 11 percent of the patients had regained consciousness; by one year, only an additional 2 percent had recovered consciousness. At one year, the majority of the children remained in a vegetative state (65 percent) or had died (22 percent). Apparent recovery of consciousness after one year has been reported in several children in a vegetative state after a hypoxic-ischemic injury119. However, these children recovered a level of function described as socially responsive, meaning that they smiled in response to the presence of other people but without other evidence of awareness. The prognosis for recovery from a vegetative state in young infants with birth injuries and perinatal asphyxia is more variable than in older infants and children3,4,58,66.
The prognosis for recovery of function in children with a nontraumatic injury is somewhat better than that for adults. Of the 13 percent of children who recovered consciousness, 6 percent had a good recovery, and the other 7 percent had severe disability; there were no reports of moderate disability.
Degenerative and Metabolic Diseases
Patients in a vegetative state due to degenerative or metabolic diseases have no possibility of recovery. Some patients may temporarily lapse into a vegetative state when systemic illness causes a reversible depression of neurologic function. This possibility must be considered before determining that a patient's vegetative state is irreversible.
Developmental Malformations
Infants and children with brain malformations severe enough to cause a developmental vegetative state are unlikely to become conscious; those who do are in most cases severely disabled. Anencephaly is the only malformation for which it is clear at birth that there is no possibility of recovery of consciousness. The complete absence of the cerebral cortex in anencephalic infants precludes consciousness20.
Other malformations diagnosed at birth may result in a vegetative state. If the patient remains in a vegetative state at three months of age, the prognosis for any improvement is quite poor10,66. Lack of evidence of consciousness in such infants by the age of six months almost completely precludes the potential for future improvement.
Verified and Unverified Late Recovery
Few patients in a persistent vegetative state have undergone a verified recovery of consciousness more than 12 months after a traumatic injury or more than 3 months after a nontraumatic injury (Table 5). One patient recovered 30 months after a traumatic brain injury; four patients recovered 8 to 22 months after a hypoxic-ischemic or cerebrovascular injury. An additional six patients, described in the study by the Traumatic Coma Data Bank, were reported to have recovered consciousness beginning one to three years after injury. Further investigation of these six patients suggests that only half recovered awareness after one year; one was moderately disabled, and the others had severe disabilities49. Two recent studies in adults and children have also reported that a few patients with traumatic and nontraumatic injuries recovered consciousness after the expected intervals119,120. The task force knows of no other cases of verified late recovery.
Several reports in the popular media have described dramatic recovery from a persistent vegetative state. In most reports, recovery of consciousness and function occurred within the time frames noted above121. Unusual cases in the medical literature or popular media are poorly documented, the nature of the patients' neurologic condition is unclear, or the timing of the entry into the vegetative state is extremely atypical114,122. A tabular summary of these cases is available from the task force. Several of these reports have been investigated by members of the task force, and it appears likely that, although the patients were not directly examined, a late recovery of consciousness did occur. The total number of such patients is extremely small, however, considering the estimated prevalence of the persistent vegetative state, and all were apparently left with severe disability.
Probability of Recovery
On the basis of the data in the series noted above, we have estimated the probability of recovery of consciousness in adults and children who were in a vegetative state one month after an acute traumatic or nontraumatic injury (Table 4). The outcome probability at 12 months was determined in patients who remained in a vegetative state at 3 months and at 6 months. In addition, the probability of functional recovery was determined for two possible outcomes: good recovery or recovery with moderate disability, and recovery with severe disability. On the basis of these probabilities, a persistent vegetative state can be judged to be permanent 12 months after a traumatic injury in adults and children; recovery after this time is exceedingly rare and almost always involves a severe disability. In adults and children with nontraumatic injuries, a persistent vegetative state can be considered to be permanent after three months; recovery does occur, but it is rare and at best associated with moderate or severe disability.
Survival
Despite the preservation of hypothalamic and brain-stem function, the severe neurologic injury necessary to produce the vegetative state in adults and children reduces the average life expectancy to approximately two to five years. Survival beyond 10 years is unusual. As shown in Figure 1 and Figure Figure Table 3, within one year after a traumatic injury, 33 percent of adults in a vegetative state had died, and 53 percent of those in a vegetative state after a nontraumatic injury had died. Among children with traumatic and nontraumatic injuries, 9 and 22 percent, respectively, had died within one year.
Overall, the available data (based on 251 patients in four large series) indicate that the mortality rate for adults in a persistent vegetative state after an acute brain injury is 82 percent at three years and 95 percent at five years33,42,51, 112 (tabular data are available from the task force). In a study of 110 patients, the mortality rate increased from 65 to 73 percent between 3 and 5 years, and 90 percent of the patients had died within 10 years; the average life expectancy of the 71 patients who died was 38.4 months42. Another study of 53 patients in a persistent vegetative state six months after an acute injury reported a mortality rate of 47 percent at three years, 76 percent at six years, and 78 percent at eight years33. The mean duration of survival was 4.4 years; five patients survived longer than 10 years.
Other investigators studying somewhat different populations of patients in a persistent vegetative state have reported similar estimates of survival. For example, in a study by Tresch and colleagues, the mean (±SD) survival of 51 patients in a persistent vegetative state in nursing homes was 3.3 ±0.5 years39. Among adults with degenerative diseases who enter a vegetative state, survival ranges from 3.5 to 7 years57. In all these, a few patients lived for periods as long as 10 to 16 years.
Estimates of the survival of infants and children in a persistent vegetative state, based on the clinical experience of pediatric neurologists, were published recently10. These estimates range from 4.1 ±0.7 years, for infants up to 2 months of age, to 7.4 ±1.8 years, for children 7 to 18 years old. A large population-based study examining 847 children and adults considered to be in a persistent vegetative state reported approximately the same duration of survival among older children but a much shorter survival among children under the age of one year40. Rare cases of survival as long as 10 to 20 years were also noted in the survey of pediatric neurologists10.
A very small number of well-described patients in a persistent vegetative state have survived for more than 15 years (data available from the task force), including three patients who survived for more than 17, 37, and 41 years29, 123,124. Considering the small total number of patients in a persistent vegetative state, the probability that an individual patient will have such a prolonged survival (i.e., over 15 years) is exceedingly low, probably less than 1 in 15,000 to 75,000 (calculations available from the task force).
The shortened life expectancy of patients in a persistent vegetative state is due to several factors. Reported causes of death (based on data from 143 patients) include infection, usually of the pulmonary or urinary tract (in 52 percent of patients); generalized systemic failure (in 30 percent); sudden death of unknown cause (in 9 percent); respiratory failure (in 6 percent); and other disease-related causes, such as recurrent strokes or tumors (in 3 percent)23,37, 112. Age is also an important factor; both young infants and children and the elderly have a shorter life expectancy than do young or middle-aged adults. Whether this is related to the cause of the vegetative state or to the risks of subsequent medical complications is unknown. In addition, there have been no formal studies of the effect of the level of care on the life expectancy of patients in a persistent vegetative state.
The costs of caring for patients in a persistent vegetative state are difficult to estimate. The cost of hospital care for the first three months is estimated to be $149,200125. The estimated cost of long-term care in a skilled nursing facility ranges from approximately $350 per day ($126,000 per year) to approximately $500 per day ($180,000 per year)124. For children in a persistent vegetative state, the estimated annual cost of care at home is $129,000 (±$51,000) for the first year and $97,000 for subsequent years126. A rough approximation of the total annual costs in the United States for the care of adults and children in a persistent vegetative state is $1 billion to $7 billion.
Pain and Suffering
The question has been raised whether patients in a persistent vegetative state can experience pain and suffering. These terms refer to the unpleasant experiences that occur in response to stimulation of peripheral nociceptive receptors and their peripheral and central afferent pathways or that may emanate endogenously from the depths of human self-perception127.
The term “nociceptive” refers only to the response to noxious stimuli, not to the experience of pain. Nociceptive responses, which can be elicited at every level of the nervous system, from the spinal cord to the thalamus, are behavioral responses governed by functional motor systems. Such responses consist of flexor spasms at the spinal level, flaccid lower extremities and extended upper extremities at the lower level of the brain stem, extensor spasms of all extremities at the upper level of the brain stem, and flexor responses in the upper extremities and extensor responses in the lower extremities at the thalamic level. None of these responses necessarily reflect the perception of pain. Nociceptive stimulation elicits well-known, unconscious postural responses, as well as other motor, autonomic, and endocrinologic reflexive responses. None of these, however, can evoke the experience of pain and suffering if the brain has lost its capacity for self-awareness. The perceptions of pain and suffering are conscious experiences: unconsciousness, by definition, precludes these experiences.
Four levels of neurologic responses to nociceptive stimuli, from unconscious responses to the experience of pain and suffering, can be recognized on the basis of current anatomical knowledge. First, monosynaptic reflex responses occur at the level of the spinal cord through synapses connecting incoming nociceptive impulses with motor responses programmed at that level. Second, simple nociception occurs at the level of the thalamus with the reception of nociceptive impulses. Third, subcortical nociceptive responses produce patterned behaviors, such as grimace-like or crying-like behavior similar to that accompanying conscious emotional responses. These responses, commonly seen in patients in a persistent vegetative state, are probably mediated at subcortical levels through synaptic connections between the thalamus and limbic system. Finally, conscious awareness of pain or the experience of suffering occurs at a cortical level through synapses connecting parietal cortical neurons with other areas of the cerebral cortex. Conscious (i.e., learned) responses to pain differ measurably from the reflexive decorticate or decerebrate postural responses that usually characterize a persistent vegetative state.
As noted in the first part of this article, extensive clinical experience, the results of positron-emission tomographic (PET) studies, and neuropathologic examination support the belief that patients in a persistent vegetative state are unaware and insensate and therefore lack the cerebral cortical capacity to be conscious of pain. Almost all such patients have some degree of motor activity and eye movement that would be capable of signaling conscious perception of pain or suffering if such existed. In rare cases, it may be difficult to distinguish a persistent vegetative state from a severe locked-in state. Under such unusual circumstances, a patient may not be able to express behavioral responses to painful stimuli or the responses may be extremely difficult to detect; the absence of a response cannot be taken as proof of the absence of consciousness21, 128.
Because the pain response is functional at all levels up to the cerebrum, but not necessarily the cortex, at birth, children of all ages are capable of responding to noxious stimuli129,130. Newborns may have the potential to experience pain and suffering. Infants over several months of age are consciously aware and capable of suffering. Children in a vegetative state may react to noxious stimuli, but for the same reason as in adults, they cannot experience pain or suffering. Such children may have involuntary responses to noxious stimuli, including alerting behavior, grunting, or grimace-like or crying-like behavior. The elicitation of these responses is unlikely to be evidence of conscious awareness of pain or suffering unless they are consistent, sustained, and definitive in nature.
Treatment
Therapy aimed at reversing the persistent vegetative state has not been successful131,132. There have been occasional reports of a benefit from dopamine agonists or dextroamphetamine, but the benefit has been modest at best, and there have been no placebo-controlled or double-blind studies133. Direct electrical stimulation of the mesencephalic reticular formation, nonspecific thalamic nuclei, or dorsal columns has been attempted experimentally in patients in a vegetative state, with claims of recovered consciousness in a few instances134-136. The quality of the recovered state was not described in detail, however, and these approaches remain experimental. Reports of improvement with coma stimulation programs have been published, but there are no verified controlled studies reported in peer-reviewed journals132,137-142. Overall, there is no published evidence that coma sensory stimulation improves the clinical outcome in patients in a persistent vegetative state.
Determining the Level of Treatment
When the diagnosis of a persistent vegetative state has been properly established, physicians have the responsibility of discussing with the family or surrogate decision makers the probability that the patient will recover or remain in a vegetative state. Physicians should also work closely with the family to determine the appropriate level of medical treatment. There are four levels of treatment: high-technology “rescue” treatments, such as mechanical ventilation, dialysis, and cardiopulmonary resuscitation; medications and other commonly ordered treatments, including antibiotics and supplemental oxygen; hydration and nutrition; and nursing or home care to maintain personal dignity and hygiene143.
When there is agreement on the appropriate level of treatment, the physicians should provide nurses, family members, or others caring for the patient with explicit written instructions about which treatments can be administered and which should be withheld. At all times, the patient's dignity and hygiene must be maintained.
If the decision is to treat the patient aggressively, diligent medical treatment and nursing care are required to prevent and treat the complications that are likely or inevitable in states of severe brain damage131. The survival of patients in a persistent vegetative state is, to some degree, related to the quality and intensity of the medical treatment and nursing care that they receive.
Preventive care is foremost. Daily exercises in a range of movements slow the formation of limb contractures, which otherwise become particularly severe in patients in a persistent vegetative state. Daily skin care and frequent repositioning of the patient prevent decubitus ulcers. A tracheostomy may be required to maintain airway patency and prevent aspiration pneumonia. Bladder and bowel care is desirable for hygienic reasons. Since pulmonary and urinary tract infections are common, appropriate monitoring and, if necessary, treatment with antibiotics are required. Placement of nasogastric, gastrostomy, or jejunostomy feeding tubes is usually necessary to maintain adequate nutrition and hydration.
Several medical societies and interdisciplinary bodies have asserted that surrogate decision makers and patients acting through advance directives have the right to terminate all forms of life-sustaining medical treatment, including hydration and nutrition, in adult patients in a persistent vegetative state2,8,11,16,17,18,41. These organizations include the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1983), the Hastings Center (1987), the American Academy of Neurology (1989), the American Medical Association (1990), and the United Kingdom Institute of Medical Ethics Working Party on the Ethics of Prolonging Life and Assisting Death (1991). Surrogates and families should be given appropriate psychosocial and religious counseling as they face decisions about termination of treatment. Specific clinical guidelines are available for physicians terminating treatment in adult patients in a persistent vegetative state8,14,18, 143. There are no well-accepted clinical guidelines for withdrawing nutrition and hydration from children in a persistent vegetative state or from adults in such a state who have never been competent. It should be emphasized that confirmation of a persistent vegetative state is not the only criterion that can or should be considered in decisions concerning life support in newborns, infants, children, or adults. Numerous judicial decisions over the past two decades have also addressed this issue, and the process of surrogate decision making may be limited or affected by the statutes of a particular state11,12, 144-149.
Few data have been collected concerning the care given to patients in a persistent vegetative state and whether the care they receive affects the incidence of medical complications or their life expectancy. An epidemiologic study of patients in a persistent vegetative state living in nursing homes found that each received an average of 3.7 prescribed medications daily and had an average of 1.2 hospitalizations during their stay in the nursing home39. Less than half the patients had do-not-resuscitate orders written in their charts.
Withdrawing Artificial Nutrition and Hydration
When artificial nutrition and hydration are withdrawn, patients in a persistent vegetative state usually die within 10 to 14 days150. The immediate cause of death is dehydration and electrolyte imbalance rather than malnutrition; patients in a persistent vegetative state cannot experience thirst or hunger151. Some patients die from intercurrent acute illnesses, such as pneumonia. Others may die from underlying cardiac or renal disease when medications are also discontinued.
Appropriate nursing care can prevent the most common signs of acute dehydration, such as dryness of the skin and mucous membranes of the mouth and eyes152. Facial swelling from prolonged administration of artificial nutrition and hydration decreases as the patient becomes progressively dehydrated; during the last few days of life, facial features may assume a more normal appearance. When dehydration leads to systemic hypotension, some patients in a vegetative state slip into a coma, whereas others continue to have periods of wakefulness and sleep-wake cycles until they die. Except for dryness of the skin and mucous membranes, it is not readily apparent to family or health care professionals that a patient in a vegetative state is dying of acute dehydration. Such patients also do not manifest the characteristic signs of malnutrition after depletion of nutrients over a prolonged period.
Future Directions
Although investigators have learned much about the persistent vegetative state over the past two decades, several areas deserve additional study. In the area of epidemiology, improved data on the incidence, prevalence, and natural history of the persistent vegetative state would be available if health authorities recorded such a state in patients, in addition to its underlying cause. More careful clinical studies of individual patients could provide data to determine which clinical findings are critical for the diagnosis of a persistent vegetative state. Future PET studies should measure regional cerebral blood flow or glucose metabolism in response to visual, auditory, and somatosensory stimulation, to determine whether depressed cortical regions in patients in a persistent vegetative state can be activated by peripheral sensory stimuli. A confirmation of the absence of evoked activity on the PET scan would help defend the assertion that patients in a persistent vegetative state are completely unaware and insensate21. Single-photon-emission computed tomography (SPECT) may be used to study changes in blood flow. SPECT findings generally parallel PET findings, but SPECT units are less expensive and more widely available. Finally, studies should include larger numbers of patients in a persistent vegetative state to establish clinical predictors of recovery of consciousness, other neurologic functions, and survival based on age, cause of the vegetative state, and other comorbid factors. Outcome studies should determine the degree of disability in patients with a late recovery of consciousness. Studies of children with developmental disorders causing a persistent vegetative state may show how they differ from patients in a vegetative state as a result of injuries or degenerative or metabolic disorders.
This statement has been approved by the American Academy of Neurology, Child Neurology Society, American Neurological Association, American Association of Neurological Surgeons, and American Academy of Pediatrics. The literature search, correspondence, and other documents generated by the task force are available through the American Academy of Neurology in Minneapolis.
We are indebted to the following people, who served as consultants to the task force and reviewed this document: George Annas, J.D., Richard Beresford, M.D., Elizabeth M. Boggs, Ph.D., Reinder Braakman, M.D., Arthur Caplan, Ph.D., John J. Caronna, M.D., Allen Childs, M.D., Peggy C. Ferry, M.D., Norman Fost, M.D., M.P.H., John Freeman, M.D., Robert G. Grossman, M.D., Deborah G. Hirtz, M.D., Bryan Jennett, M.D., Howard H. Kaufman, M.D., Arthur F. Kohrman, M.D., Robert L. Kriel, M.D., Nicholas J. Lenn, M.D., David E. Levy, M.D., Thomas G. Luerssen, M.D., Joanne Lynn, M.D., Lawrence F. Marshall, M.D., Robert L. McLaurin, M.D., Michael P. McQuillen, M.D., Jan M. Minderhoud, M.D., Patricia A. Murphy, R.N., Allan H. Ropper, M.D., Jay Rosenberg, M.D., Leon Sazbon, M.D., Alan Shewmon, M.D., David A. Stumpf, M.D., Francois Tasseau, M.D., H. Rutherford Turnbull III, Kenneth A. Vatz, M.D., and Deborah Webb, R.N.
Source Information
Address reprint requests to the Multi-Society Task Force on PVS, American Academy of Neurology, 2221 University Ave. S.E., Minneapolis, MN 55414.
The members of the task force are Stephen Ashwal, M.D., cochairman (Loma Linda University School of Medicine, Loma Linda, Calif.), Child Neurology Society; Ronald Cranford, M.D., cochairman (Hennepin County Medical Center, Minneapolis), American Academy of Neurology; James L. Bernat, M.D. (Dartmouth Medical School, Hanover, N.H.), American Academy of Neurology; Gastone Celesia, M.D. (Loyola University Stritch School of Medicine, Maywood, Ill.), American Neurological Association; David Coulter, M.D. (Boston University School of Medicine, Boston), Child Neurology Society; Howard Eisenberg, M.D. (Maryland Institute of Emergency Medical Services Systems, Baltimore), American Association of Neurological Surgeons; Edwin Myer, M.D. (Medical College of Virginia, Richmond), American Academy of Pediatrics; Fred Plum, M.D. (New York Hospital-Cornell University Medical College, New York), American Neurological Association; Marion Walker, M.D. (Primary Children's Hospital and Medical Center, Salt Lake City), American Academy of Pediatrics; Clark Watts, M.D. (University of Texas Health Sciences Center, San Antonio), American Association of Neurological Surgeons; and Teresa Rogstad, project coordinator, American Academy of Neurology.
- References
References
108
Jennett B ,Bond M . Assessment of outcome after severe brain damage: a practical scale. Lancet 1975;1:480-484
CrossRef | Web of Science | Medline109
Alberico AM ,Ward JD ,Choi SC ,Marmarou A ,Young HF . Outcome after severe head injury: relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients. J Neurosurg 1987;67:648-656
CrossRef | Web of Science | Medline110
Groswasser Z ,Sazbon L . Outcome in 134 patients with prolonged posttraumatic unawareness: part 2: functional outcome of 72 patients recovering consciousness. J Neurosurg 1990;72:81-84
CrossRef | Web of Science | Medline111
Arts WFM ,Van Dongen HR ,Van Hof-Van Duin J ,Lammens E . Unexpected improvement after prolonged posttraumatic vegetative state. J Neurol Neurosurg Psychiatry 1985;48:1300-1303
CrossRef | Web of Science | Medline112
Sazbon L ,Groswasser Z . Medical complications and mortality of patients in the postcomatose unawareness (PC-U) state. Acta Neurochir (Wien) 1991;112:110-112
CrossRef | Web of Science | Medline113
Falk RH . Physical and intellectual recovery following prolonged hypoxic coma. Postgrad Med J 1990;66:384-386
CrossRef | Web of Science | Medline114
Tanhehco J ,Kaplan PE . Physical and surgical rehabilitation of patient after 6-year coma. Arch Phys Med Rehabil 1982;63:36-38
Web of Science | Medline115
Rosenberg GA ,Johnson SF ,Brenner RP . Recovery of cognition after prolonged vegetative state. Ann Neurol 1977;2:167-168
CrossRef | Web of Science116
Snyder BD ,Cranford RE ,Rubens AB ,Bundlie S ,Rockswold GE . Delayed recovery from postanoxic persistent vegetative state. Ann Neurol 1983;14:152-152 abstract.
Web of Science117
Lange-Cosack H ,Riebel U ,Grumme T ,Schlesener HJ . Possibilities and limitations of rehabilitation after traumatic apallic syndrome in children and adolescents. Neuropediatrics 1981;12:337-365
CrossRef | Web of Science | Medline118
Kriel RL ,Krach LE ,Sheehan M . Pediatric closed head injury: outcome following prolonged unconsciousness. Arch Phys Med Rehabil 1988;69:678-681
Web of Science | Medline119
Kriel RL ,Krach LE ,Jones-Saete C . Outcome of children with prolonged unconsciousness and vegetative states. Pediatr Neurol 1993;9:362-368
CrossRef | Web of Science | Medline120
Andrews K . Recovery of patients after four months or more in the persistent vegetative state. BMJ 1993;306:1597-1600
CrossRef | Web of Science | Medline121
Cole HA, Jablow MM. One in a million. Boston: Little, Brown, 1990.
122
Steinbock B . Recovery from the persistent vegetative state? The case of Carrie Coons. Hastings Cent Rep 1989;19:14-15
Web of Science | Medline123
Sibbison JB . USA: right to live, or right to die? Lancet 1991;337:102-103
CrossRef | Medline124
Field RE ,Romanus RJ . A decerebrate patient: eighteen years of care. Conn Med 1981;45:717-723
Medline125
Papastrat LA. Guidelines for reserving: traumatic brain injury. Princeton, N.J.: American Re-Insurance Company, 1990.
126
Fields AI ,Coble DH ,Pollack MM ,Cuerdon TT ,Kaufman J . Outcomes of children in a persistent vegetative state. Crit Care Med 1993;21:1890-1894
CrossRef | Web of Science | Medline127
Casey KL, ed. Pain and central nervous system disease: the central pain syndromes: the Bristol-Myers Squibb Symposium on Pain Research. New York: Raven Press, 1991.
128
McQuillen MP . Can people who are unconscious or in the “vegetative state” perceive pain? Issues Law Med 1991;6:373-383
Web of Science | Medline129
Anand KJS ,Hickey PR . Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317:1321-1329
Full Text | Web of Science | Medline130
The plasticity and complexity of the nociceptive system. In: McGrath PA. Pain in children: nature, assessment, and treatment. Vol. 2 of Comprehensive neurologic rehabilitation. New York: Guilford Press, 1990:88-110.
131
Whyte J, Glenn MB. Management of the patient in a persistent vegetative state: current status and needed research. In: Bach-y-Rita P, ed. Traumatic brain injury. New York: Demos Publications, 1989:13-29.
132
Wood RL . Critical analysis of the concept of sensory stimulation for patients in vegetative states. Brain Inj 1991;5:401-409
CrossRef | Medline133
Haig AJ ,Ruess JM . Recovery from vegetative state of six months' duration associated with Sinemet (levodopa/carbidopa). Arch Phys Med Rehabil 1990;71:1081-1083
Web of Science | Medline134
Tsubokawa T ,Yamamoto T ,Katayama Y ,Hirayama T ,Maejima S ,Moriya T . Deep-brain stimulation in a persistent vegetative state: follow-up results and criteria for selection of candidates. Brain Inj 1990;4:315-327
CrossRef | Medline135
Kanno T ,Kamel Y ,Yokoyama T ,Shoda M ,Tanji H ,Nomura M . Effects of dorsal column spinal cord stimulation (DCS) on reversibility of neuronal function -- experience of treatment for vegetative states. Pacing Clin Electrophysiol 1989;12:733-738
CrossRef | Web of Science | Medline136
Katayama Y ,Tsubokawa T ,Yamamoto T ,Hirayama T ,Miyazaki S ,Koyama S . Characterization and modification of brain activity with deep brain stimulation in patients in a persistent vegetative state: pain-related late positive component of cerebral evoked potential. Pacing Clin Electrophysiol 1991;14:116-121
CrossRef | Web of Science | Medline137
LeWinn EB ,Dimancescu MD . Environmental deprivation and enrichment in coma. Lancet 1978;2:156-157
CrossRef | Web of Science | Medline138
DeYoung S ,Grass RB . Coma recovery program. Rehabil Nurs 1987;12:121-124
Medline139
Wood RL ,Winkowski TB ,Miller JL ,Tierney L ,Goldman L . Evaluating sensory regulation as a method to improve awareness in patients with altered states of consciousness: a pilot study. Brain Inj 1992;6:411-418
CrossRef | Medline140
Andrews K . Managing the persistent vegetative state. BMJ 1992;305:486-487
CrossRef | Web of Science | Medline141
Doman G ,Wilkinson R ,Dimancescu MD ,Pelligra R . The effect of intense multi-sensory stimulation on coma arousal and recovery. Neuropsychol Rehabil 1993;3:202-212
CrossRef142
Pierce JP ,Lyle DM ,Quine S ,Evans NJ ,Morris J ,Fearnside MR . The effectiveness of coma arousal intervention. Brain Inj 1990;4:191-197
CrossRef | Medline143
Cranford RE . Termination of treatment in the persistent vegetative state. Semin Neurol 1984;4:36-44
CrossRef | Web of Science | Medline144
National Center for State Courts. Guidelines for state court decision making in the life-sustaining medical treatment cases. 2nd ed. rev. St. Paul, Minn.: West Publishing, 1993.
145
Hastings Center. Guidelines on the termination of life-sustaining treatment and care of the dying. Briarcliff Manor, N.Y.: Hastings Center, 1987.
146
Jennett B ,Boyd KM . Managing the persistent vegetative state. BMJ 1992;305:886-887
CrossRef | Web of Science | Medline147
Jennett B . Letting vegetative patients die. BMJ 1992;305:1305-1306
CrossRef | Web of Science | Medline148
Weiner JD . Legal issues regarding patients in coma or in persistent vegetative state. Phys Med Rehabil 1990;4:569-578149
Weir RF ,Gostin L . Decisions to abate life-sustaining treatment for nonautonomous patients: ethical standards and legal liability for physicians after Cruzan. JAMA 1990;264:1846-1853
CrossRef | Web of Science | Medline150
Alfonso I ,Lanting WA ,Duenas D ,Cullen RF ,Papazian O . Discontinuation of artificial hydration and nutrition in hopelessly vegetative children. Ann Neurol 1992;32:454-455 abstract.151
Ahronheim JC ,Gasner MR . The sloganism of starvation. Lancet 1990;335:278-279
CrossRef | Web of Science | Medline152
Printz LA . Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 1988;43:84-88
Web of Science | Medline
- Citing Articles (101)
Citing Articles
1
A. Demertzi, E. Racine, M-A. Bruno, D. Ledoux, O. Gosseries, A. Vanhaudenhuyse, M. Thonnard, A. Soddu, G. Moonen, S. Laureys. (2012) Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue. Neuroethics
CrossRef2
Enrique Noé, José Olaya, M. Dolores Navarro, Paloma Noguera, Carolina Colomer, Javier García-Panach, Sandra Rivero, Belén Moliner, Joan Ferri. (2012) Behavioral Recovery in Disorders of Consciousness: A Prospective Study With the Spanish Version of the Coma Recovery Scale–Revised. Archives of Physical Medicine and Rehabilitation
CrossRef3
Martin M. Monti, John D. Pickard, Adrian M. Owen. (2012) Visual cognition in disorders of consciousness: From V1 to top-down attention. Human Brain Mappingn/a-n/a
CrossRef4
Sandrine de Ribaupierre. (2011) Trauma and Impaired Consciousness. Neurologic Clinics 29:4, 883-902
CrossRef5
Emily B. Rubin, James L. Bernat. (2011) Ethical Aspects of Disordered States of Consciousness. Neurologic Clinics 29:4, 1055-1071
CrossRef6
Connie C. Duncan, Angela C. Summers, Elizabeth J. Perla, Kerry L. Coburn, Allan F. Mirsky. (2011) Evaluation of traumatic brain injury: Brain potentials in diagnosis, function, and prognosis. International Journal of Psychophysiology 82:1, 24-40
CrossRef7
Johann Donis, Bernd Kräftner. (2011) The prevalence of patients in a vegetative state and minimally conscious state in nursing homes in Austria. Brain Injury 25:11, 1101-1107
CrossRef8
Natallia Lapitskaya, Joergen Feldbaek Nielsen, Anders Fuglsang-Frederiksen. (2011) Robotic gait training in patients with impaired consciousness due to severe traumatic brain injury. Brain Injury 25:11, 1070-1079
CrossRef9
Kunal Khanna, Ajit Verma, Bella Richard. (2011) “The locked-in syndrome”: Can it be unlocked?. Journal of Clinical Gerontology and Geriatrics
CrossRef10
J. P. Bishop, D. R. Morrison. (2011) The Roman Catholic Church, Biopolitics, and the Vegetative State. Christian Bioethics 17:2, 165-184
CrossRef11
Seth L. Brindis, Marianne Gausche-Hill, Kelly D. Young, Brant Putnam. (2011) Universally Poor Outcomes of Pediatric Traumatic Arrest. Pediatric Emergency Care 27:7, 616-621
CrossRef12
A. Demertzi, D. Ledoux, M.-A. Bruno, A. Vanhaudenhuyse, O. Gosseries, A. Soddu, C. Schnakers, G. Moonen, S. Laureys. (2011) Attitudes towards end-of-life issues in disorders of consciousness: a European survey. Journal of Neurology 258:6, 1058-1065
CrossRef13
Marco Luchetti, Giuseppe Nattino. 2011. Nutritional Support in the Vegetative State. , 345-355.
CrossRef14
Solomon O. Ugoya, Rufus O. Akinyemi. (2010) The Place of l-Dopa/Carbidopa in Persistent Vegetative State. Clinical Neuropharmacology 33:6, 279-284
CrossRef15
Suvasini Sharma, Gurpreet Singh Kochar, Naveen Sankhyan, Sheffali Gulati. (2010) Approach to the Child with Coma. The Indian Journal of Pediatrics 77:11, 1279-1287
CrossRef16
Takamitsu Yamamoto, Yoichi Katayama, Kazutaka Kobayashi, Hideki Oshima, Chikashi Fukaya, Takashi Tsubokawa. (2010) Deep brain stimulation for the treatment of vegetative state. European Journal of Neuroscience 32:7, 1145-1151
CrossRef17
Deborah Doherty. 2010. Neuropharmacologic Considerations in the Treatment of Vegetative State and Minimally Conscious State Following Brain Injury. , 167-192.
CrossRef18
Alan Weintraub, Mark Ashley. 2010. Issues in Aging Following Traumatic Brain Injury. , 381-418.
CrossRef19
Kurt A Jellinger. 2010. Brain Death and the Vegetative State. .
CrossRef20
Horst J. Koch, Thomas Hutterer. (2010) Circadian rhythm of vital functions in patients with severe cerebral hypoxia at time of admission and discharge in a neurological rehabilitation intensive care unit: a retrospective pilot study. Biological Rhythm Research 41:2, 83-89
CrossRef21
Tristan A Bekinschtein, Diego E Shalom, Cecilia Forcato, Maria Herrera, Martin R Coleman, Facundo F Manes, Mariano Sigman. (2009) Classical conditioning in the vegetative and minimally conscious state. Nature Neuroscience 12:10, 1343-1349
CrossRef22
Eike-Henner W. Kluge. (2009) Quality-of-life considerations in substitute decision-making for severely disabled neonates: The problem of developing awareness. Theoretical Medicine and Bioethics 30:5, 351-366
CrossRef23
B.A. Manninen,. (2009) Defining Human Death: An Intersection of Bioethics and Metaphysics. Reviews in the Neurosciences 20:3-4, 283-292
CrossRef24
Sergio Castrejón, Marcelino Cortés, María L. Salto, Luiz C. Benittez, Rafael Rubio, Miriam Juárez, Esteban López de Sá, Héctor Bueno, Pedro L. Sánchez, Francisco Fernández Avilés. (2009) Mejora del pronóstico tras parada cardiorrespiratoria de causa cardiaca mediante el empleo de hipotermia moderada: comparación con un grupo control. Revista Española de Cardiología 62:7, 733-741
CrossRef25
Geoffrey Ling, Faris Bandak, Rocco Armonda, Gerald Grant, James Ecklund. (2009) Explosive Blast Neurotrauma. Journal of Neurotrauma 26:6, 815-825
CrossRef26
Joseph J. Fins. (2009) Being Conscious of Their Burden. Annals of the New York Academy of Sciences 1157:1, 131-147
CrossRef27
Tetsuo Kanno, Isao Morita, Sachiko Yamaguchi, Tetsuya Yokoyama, Yoshifumi Kamei, S. M. Anil, Kostadin L. Karagiozov. (2009) Dorsal Column Stimulation in Persistent Vegetative State. Neuromodulation: Technology at the Neural Interface 12:1, 33-38
CrossRef28
J. P. Bishop. (2008) Biopolitics, Terri Schiavo, and the Sovereign Subject of Death. Journal of Medicine and Philosophy 33:6, 538-557
CrossRef29
Jae H. Choi, Michael Jakob, Christian Stapf, Randolph S. Marshall, Andreas Hartmann, Henning Mast. (2008) Multimodal Early Rehabilitation and Predictors of Outcome in Survivors of Severe Traumatic Brain Injury. The Journal of Trauma: Injury, Infection, and Critical Care 65:5, 1028-1035
CrossRef30
Athena Demertzi, Audrey Vanhaudenhuyse, Marie-Aurélie Bruno, Caroline Schnakers, Mélanie Boly, Pierre Boveroux, Pierre Maquet, Gustave Moonen, Steven Laureys. (2008) Is there anybody in there? Detecting awareness in disorders of consciousness. Expert Review of Neurotherapeutics 8:11, 1719-1730
CrossRef31
Roberto Aquilani, Mirella Boselli, Federica Boschi, Simona Viglio, Paolo Iadarola, Maurizia Dossena, Ornella Pastoris, Manuela Verri. (2008) Branched-Chain Amino Acids May Improve Recovery From a Vegetative or Minimally Conscious State in Patients With Traumatic Brain Injury: A Pilot Study. Archives of Physical Medicine and Rehabilitation 89:9, 1642-1647
CrossRef32
Adrian M. Owen, Martin R. Coleman. (2008) Detecting Awareness in the Vegetative State. Annals of the New York Academy of Sciences 1129:1, 130-138
CrossRef33
Christina Kwasnica, Allen W. Brown, Elie P. Elovic, Sunil Kothari, Steven R. Flanagan. (2008) Congenital and Acquired Brain Injury. 3. Spectrum of the Acquired Brain Injury Population. Archives of Physical Medicine and Rehabilitation 89:3, S15-S20
CrossRef34
PAULA M. SUTER, JANICE ROGERS, CARMEN STRACK. (2008) Artificial Nutrition and Hydration for the Terminally Ill. Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 26:1, 23-29
CrossRef35
Aliaksei Pustavoitau, Robert D. Stevens. (2008) Mechanisms of Neurologic Failure in Critical Illness. Critical Care Clinics 24:1, 1-24
CrossRef36
M. Bertram, T. Brandt. (2007) Neurologisch-neurochirurgische Frührehabilitation. Der Nervenarzt 78:10, 1160-1174
CrossRef37
Heidi Ammermann, Jan Kassubek, Martin Lotze, Ernst Gut, Michael Kaps, Joachim Schmidt, Frank A. Rodden, Wolfgang Grodd. (2007) MRI brain lesion patterns in patients in anoxia-induced vegetative state. Journal of the Neurological Sciences 260:1-2, 65-70
CrossRef38
Robert D. Truog. (2007) Brain Death - Too Flawed to Endure, Too Ingrained to Abandon. The Journal of Law, Medicine & Ethics 35:2, 273-281
CrossRef39
Sean P. Keenan, Peter Dodek, Claudio Martin, Fran Priestap, Monica Norena, Hubert Wong. (2007) Variation in length of intensive care unit stay after cardiac arrest: Where you are is as important as who you are. Critical Care Medicine 35:3, 836-841
CrossRef40
JIM STONE. (2007) PASCAL'S WAGER AND THE PERSISTENT VEGETATIVE STATE. Bioethics 21:2, 84-92
CrossRef41
Joseph J. Fins. (2007) Border Zones of Consciousness: Another Immigration Debate?. The American Journal of Bioethics 7:1, 51-54
CrossRef42
F. Mauguière, C. Fischer, N. André-Obadia. (2007) Potenziali evocati in neurologia: risposte patologiche e indicazioni. EMC - Neurologia 7:3, 1-29
CrossRef43
Steven Laureys, Joseph T Giacino, Nicholas D Schiff, Manuel Schabus, Adrian M Owen. (2006) How should functional imaging of patients with disorders of consciousness contribute to their clinical rehabilitation needs?. Current Opinion in Neurology 19:6, 520-527
CrossRef44
Joseph T. Giacino, Joy Hirsch, Nicholas Schiff, Steven Laureys. (2006) Functional Neuroimaging Applications for Assessment and Rehabilitation Planning in Patients With Disorders of Consciousness. Archives of Physical Medicine and Rehabilitation 87:12, 67-76
CrossRef45
Chad D. Kollas, Beth Boyer-Kollas. (2006) Closing the Schiavo Case: An Analysis of Legal Reasoning. Journal of Palliative Medicine 9:5, 1145-1163
CrossRef46
Hyeong-Joong Yi, Young-Soo Kim, Yong Ko, Suck-Jun Oh, Kwang-Myung Kim, Seong-Hoon Oh. (2006) Factors Associated with Survival and Neurological Outcome after Cardiopulmonary Resuscitation of Neurosurgical Intensive Care Unit Patients. Neurosurgery 59:4, 838-846
CrossRef47
R STEVENS, P NYQUIST. (2006) Coma, Delirium, and Cognitive Dysfunction in Critical Illness. Critical Care Clinics 22:4, 787-804
CrossRef48
Viona J.M. Wijnen, Matagne Heutink, Geert J.M. van Boxtel, Henk J. Eilander, Beatrice de Gelder. (2006) Autonomic reactivity to sensory stimulation is related to consciousness level after severe traumatic brain injury. Clinical Neurophysiology 117:8, 1794-1807
CrossRef49
Nathan D Zasler. (2006) Neurorehabilitation issues in states of disordered consciousness following traumatic brain injury. Future Neurology 1:4, 439-452
CrossRef50
JOSEPH J. FINS. (2006) Affirming the right to care, preserving the right to die: Disorders of consciousness and neuroethics after Schiavo. Palliative & Supportive Care 4:02,
CrossRef51
Catherine Fischer, Jacques Luaut??, Chantal N??moz, Dominique Morlet, Gilbert Kirkorian, Fran??ois Maugui??re. (2006) Improved prediction of awakening or nonawakening from severe anoxic coma using tree-based classification analysis*. Critical Care Medicine 34:5, 1520-1524
CrossRef52
Neal H. Cohen, Heidi B. Kummer. (2006) Ethics update: lessons learned from Terri Schiavo: the importance of healthcare proxies in clinical decision-making. Current Opinion in Anaesthesiology 19:2, 122-126
CrossRef53
Lori A. Roscoe, Hana Osman, William E. Haley. (2006) Implications of the Schiavo Case for Understanding Family Caregiving Issues at the End of Life. Death Studies 30:2, 149-161
CrossRef54
Maria Andrews, Mary Marian. (2006) Ethical Framework for the Registered Dietitian in Decisions Regarding Withholding/Withdrawing Medically Assisted Nutrition and Hydration. Journal of the American Dietetic Association 106:2, 206-208
CrossRef55
Robert D. Stevens, Anish Bhardwaj. (2006) Approach to the comatose patient. Critical Care Medicine 34:1, 31-41
CrossRef56
Steven Laureys. (2005) Science and society: Death, unconsciousness and the brain. Nature Reviews Neuroscience 6:11, 899-909
CrossRef57
Ari R. Joffe. (2005) Are somatosensory evoked potentials the best predictor of outcome after severe brain injury? Caution in interpreting a systematic review. Intensive Care Medicine 31:10, 1457-1457
CrossRef58
DaiWai M. Olson, Carmelo Graffagnino. (2005) Consciousness, Coma, and Caring for the Brain-injured Patient. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 16:4, 441-455
CrossRef59
Sharon M. Weinstein. (2005) Lessons learned from the case of Theresa Marie Schiavo: One palliative care doctor’s perspective. Current Pain and Headache Reports 9:4, 223-225
CrossRef60
Lofty L. Basta, Lofty L. Basta. (2005) Ethical Issues in the Management of Geriatric Cardiac Patients. Special Report: The end of a person: brain formulation of death. Cardiac arrest no longer defines the end of life.. The American Journal of Geriatric Cardiology 14:4, 200-204
CrossRef61
Jan Lavrijsen, Ger van Rens, Hans van den Bosch. (2005) Filamentary Keratopathy as a Chronic Problem in the Long-Term Care of Patients in a Vegetative State. Cornea 24:5, 620-622
CrossRef62
Gisela Bockenheimer-Lucius. (2005) „Wachkoma“ und Ethik. Ethik in der Medizin 17:2, 85-89
CrossRef63
Annas, George J., . (2005) “Culture of Life” Politics at the Bedside — The Case of Terri Schiavo. New England Journal of Medicine 352:16, 1710-1715
Full Text64
Freimut D. Juengling, Jan Kassubek, Hans-Jürgen Huppertz, Thomas Krause, Thomas Els. (2005) Separating functional and structural damage in persistent vegetative state using combined voxel-based analysis of 3-D MRI and FDG-PET. Journal of the Neurological Sciences 228:2, 179-184
CrossRef65
Shari Hughes, Angela Colantonio, P. Lina Santaguida, Thomas Paton. (2005) Amantadine to enhance readiness for rehabilitation following severe traumatic brain injury. Brain Injury 19:14, 1197-1206
CrossRef66
Reinhard Merkel. (2004) Zur Frage der Verbindlichkeit von Patientenverf
gungen. Ethik in der Medizin 16:3, 298-307
CrossRef67
Melissa C. Bush, Sandor Nagy, Richard L. Berkowitz, Sreedhar Gaddipati. (2003) Pregnancy in a Persistent Vegetative State:. Obstetrical & Gynecological Survey 58:11, 738-748
CrossRef68
Robert D. Truog, Walter M. Robinson. (2003) Role of brain death and the dead-donor rule in the ethics of organ transplantation. Critical Care Medicine 31:9, 2391-2396
CrossRef69
Jan Kassubek, Freimut D Juengling, Thomas Els, Joachim Spreer, Martin Herpers, Thomas Krause, Ernst Moser, Carl H Lücking. (2003) Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: a 15O–H2O PET study. Journal of the Neurological Sciences 212:1-2, 85-91
CrossRef70
G. Bryan Young. (2003) Clinical neurophysiologic assessment of comatose patients *. Critical Care Medicine 31:3, 994
CrossRef71
Lawrence R. Robinson, Paula J. Micklesen, David L. Tirschwell, Henry L. Lew. (2003) Predictive value of somatosensory evoked potentials for awakening from coma*. Critical Care Medicine 31:3, 960-967
CrossRef72
Lawrence J. Nelson. (2003) Respect for the developmentally disabled and forgoing life-sustaining treatment. Mental Retardation and Developmental Disabilities Research Reviews 9:1, 3-9
CrossRef73
J. J. Pandit, B. Schmelzle-Lubiecki, M. Goodwin, N. Saeed. (2002) Bispectral index-guided management of anaesthesia in permanent vegetative state. Anaesthesia 57:12, 1190-1194
CrossRef74
S. Laureys, M.E. Faymonville, P. Peigneux, P. Damas, B. Lambermont, G. Del Fiore, C. Degueldre, J. Aerts, A. Luxen, G. Franck, M. Lamy, G. Moonen, P. Maquet. (2002) Cortical Processing of Noxious Somatosensory Stimuli in the Persistent Vegetative State. NeuroImage 17:2, 732-741
CrossRef75
D NIERMAN. (2002) A structure of care for the chronically critically ill. Critical Care Clinics 18:3, 477-491
CrossRef76
Francesco FL Lombardi, Mariangela Taricco, Antonio De Tanti, Elena Telaro, Alessandro Liberati, Francesco FL Lombardi. 2002. Sensory stimulation for brain injured individuals in coma or vegetative state. .
CrossRef77
Bryan Jennett. 2001. Brain Death and the Vegetative State. .
CrossRef78
David J Strauss, Stephen Ashwal, Steven M Day, Robert M Shavelle. (2000) Life expectancy of children in vegetative and minimally conscious states. Pediatric Neurology 23:4, 312-319
CrossRef79
P Schmidt, R Dettmeyer, B Madea. (2000) Withdrawal of artificial nutrition in the persistent vegetative state: a continuous controversy. Forensic Science International 113:1-3, 505-509
CrossRef80
G. Bryan Young. (2000) Ethics in the Intensive Care Unit with Emphasis on Medical Futility in Comatose Survivors of Cardiac Arrest. Journal of Clinical Neurophysiology 17:5, 453-456
CrossRef81
B. T. Ayorinde, I. Scudamore, D. J. Buggy. (2000) Anaesthetic management of a pregnant patient in a persistent vegetative state. British Journal of Anaesthesia 85:3, 479-481
CrossRef82
Peter D. Patrick, Sean T. Patrick, Julie D. Poole, Sharon Hostler. (2000) Evaluation and treatment of the vegetative and minimally conscious child: a single subject design. Behavioral Interventions 15:3, 225-242
CrossRef83
W. Daniel Doty, Robert M. Walker. (2000) Medical futility. Clinical Cardiology 23:S2, 6-16
CrossRef84
Andreas Kampfl, Erich Schmutzhard, Gerhard Franz, Bettina Pfausler, Hans-Peter Haring, Hanno Ulmer, Stefan Felber, Stefan Golaszewski, Franz Aichner. (1998) Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging. The Lancet 351:9118, 1763-1767
CrossRef85
Andreas Kampfl, Gerhard Franz, Franz Aichner, Bettina Pfausler, Hans-Peter Haring, Stefan Felber, Gabriele Luz, Michael Schocke, Erich Schmutzhard. (1998) The persistent vegetative state after closed head injury: clinical and magnetic resonance imaging findings in 42 patients. Journal of Neurosurgery 88:5, 809-816
CrossRef86
M.Elizabeth Sandel, Kathleen R. Bell, Linda J. Michaud. (1998) 1. Traumatic brain injury: Prevention, pathophysiology, and outcome prediction. Archives of Physical Medicine and Rehabilitation 79:3, S3-S9
CrossRef87
Michael W. O'Dell, Kathleen R. Bell, M.Elizabeth Sandel. (1998) 3. Specific disorders. Archives of Physical Medicine and Rehabilitation 79:3, S16-S20
CrossRef88
David B. Waisel, Robert D. Truog. (1997) The End-of-life Sequence. Anesthesiology 87:3, 676-686
CrossRef89
Adam Zeman. (1997) Persistent vegetative state. The Lancet 350:9080, 795-799
CrossRef90
Davina Richardson. (1997) To treat or not to treat — PVS or is he?. Physiotherapy Research International 2:2, 1-6
CrossRef91
Brody, Howard, , Campbell, Margaret L., , Faber-Langendoen, Kathy, , Ogle, Karen S., . (1997) Withdrawing Intensive Life-Sustaining Treatment — Recommendations for Compassionate Clinical Management. New England Journal of Medicine 336:9, 652-657
Full Text92
Andrew Grubb, Pat Walsh, Neil Lambe, Trevor Murrells, Sarah Robinson. (1996) Survey of British clinicians' views on management of patients in persistent vegetative state. The Lancet 348:9019, 35-40
CrossRef93
(1996) Late Improvement after Post-Traumatic Vegetative State. New England Journal of Medicine 334:18, 1201-1202
Full Text94
Danuta Mendelson. (1996) Historical evolution and modern implications of concepts of consent to, and refusal of, medical treatment in the law of trespass. Journal of Legal Medicine 17:1, 1-71
CrossRef95
Philip R. Sullivan. (1996) Physicians and the Problem of Other Consciousnesses. The Southern Journal of Philosophy 34:1, 115-123
CrossRef96
Childs, Nancy L., Mercer, Walt N., . (1996) Late Improvement in Consciousness after Post-Traumatic Vegetative State. New England Journal of Medicine 334:1, 24-25
Full Text97
Maryella D. Sirmon. (1996) The Combative Patient: Ethical Issues in Patient Selection for Chronic Dialysis. Seminars in Dialysis 9:1, 56-60
CrossRef98
Concezione Tommasino. (1995) Coma and Vegetative State Are Not Interchangeable Terms. Anesthesiology 83:4, 888
CrossRef99
Ashwal, Stephen, Cranford, Ron, . (1995) Medical Aspects of the Persistent Vegetative State -- A Correction. New England Journal of Medicine 333:2, 130-130
Full Text100
Lawrence J. Nelson, Cindy Hylton Ruston, Ronald E. Cranford, Robert M. Nelson, Jacqueline J. Glover, Robert D. Truog. (1995) Forgoing Medically Provided Nutrition and Hydration in Pediatric Patients. The Journal of Law, Medicine & Ethics 23:1, 33-46
CrossRef101
(1994) Withdrawing Treatment in the Persistent Vegetative State. New England Journal of Medicine 331:20, 1382-1383
Full Text
- Letters
